| NPI | 1164957247 |
|---|---|
| Entity Type | Individual |
| Gender | Male |
| Sole Proprietor ? | Yes |
| Primary Taxonomy | 207Q00000X Family Medicine (Licence: MA 1026103) |
| Additional Taxonomies | 207Q00000X Family Medicine (Licence: FL ME175759) |
| Enumeration Date | 2017-04-26 |
| Last Update Date | 2026-07-08 |